This document contains 40 figures showing various bone and soft tissue abnormalities. The figures demonstrate a variety of pathological conditions through radiographs, CT, MRI, bone scans and other imaging modalities. Examples include fibrous cortical defects, non-ossifying fibromas, desmoplastic fibromas, fibrosarcomas, giant cell tumors, aneurysmal bone cysts, haemangiomas, neurofibromas and other conditions. Each figure is labeled and captioned to identify the specific anatomical location and imaging findings of the abnormality shown.

1. 40 DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 40.1 Fibrous cortical defect arising in
posteromedial aspect of the distal medial
femur. (A) The abnormality is confined to
the cortex with very fine shell of overlying
bone and a sharply defined endosteal
margin. (B) A bone scan demonstrates a
slight increase in activity (arrow) at the site
of the lesion.

4. • Fig. 40.2 Fibrous
cortical defect in the
upper medial tibia is
shown on CT (arrow).
Note the purely cortical
position of the defect
and its sharply defined
margin. The thin shell
of overlying bone is not
seen completely
because of the partial
volume effect.

5. • Fig. 40.3 Non-ossifying
fibroma of the distal
tibia presenting with a
fracture. The well-
defined outline and
eccentric position of the
tumour are
demonstrated together
with sharply defined
sclerotic margins.

6. • Fig. 40.4 Sclerosis of a non-ossifying fibroma. Incidental finding
following multiple ligamentous injuries to the knee. (A)
Conventional radiograph. Only a faint band of sclerosis is shown
around the margins of the fibroma (arrows). Coronal T,-weighted (B)
and STIR (C) MR images showing mixed fibrous and normal marrow
replacement (arrows) within the involuted lesion. Tears of the
anterior cruciate and medial collateral ligaments are also evident.

7. • Fig. 40.5 Desmoplastic
fibroma. A destructive,
lobulated lesion is present
in the distal metadiaphysis
of the humerus. Bone
expansion is present with
sclerotic margins around
the tumour. A soft-tissue
component has caused
consolidated periosteal new
bone formation.

8. • Fig. 40.6 Fibrosarcoma
presenting with
pathological fracture of
the femur in a woman of
50. Ill-defined bone
destruction, particularly
of the medulla, is
associated with very
minor periosteal new
bone formation and no
sclerosis. The cortex has
been thinned on the
endosteal surface.

9. Fig. 40.7 Fibrosarcoma arising in the medulla of the femoral head and
neck. This 35-year-old man presented with poorly localised pain in
the hip. (A) At presentation an ill-defined area of bone destruction
on the medial aspect of the femoral head and neck. The cortex is
preserved with no new bone formation. (B) Three months later a
pathological fracture has occurred through the destructive lesion.

10. • Fig. 40.8 Malignant fibrous histiocytoma arising in the sacral ala of a 60-
year-old woman. (A) A purely destructive, lytic lesion is present with
slight sclerosis around its margins. Note that the lower border of L5 has
also been destroyed together with part of the iliac wing. (B) A radionuclide
bone scan shows the tumour to be photon deficient but a rim of increased
activity corresponds to reactive bone sclerosis.

11. • Fig. 40.9 Adamantinoma of
the tibia. Eccentric areas of
bone destruction are present
anteriorly with thinning of the
cortex. The cortex is
expanded. In addition to this
abnormality, sclerosis and ill-
defined cortical thickening are
present throughout the whole
of the tibia, which is also
bowed. These features are due
to associated fibrous dysplasia
(or a close variety sometimes
known as ossifying fibroma
which occurs only at this site).
(A) AP view. (B) Lateral view.

12. • Fig. 40.10 Giant cell
tumour arising in the
distal radius of an adult
man. A characteristic,
eccentric, immediately
subarticular position
makes this diagnosis
very probable. The
margins are ill defined
with no sclerotic
reaction.

13. • Fig. 40.11 Giant cell
tumour of the patella.
Giant cell tumours can
arise in almost any bone
but those around the knee
are particularly affected.
Note the immediately
subarticular, eccentric
position of the tumour
which is purely osteolytic
with no sclerotic reaction.
The epiphyses have fused.

14. • Fig. 40.12 Giant cell tumour of the distal femur. AP (A) and lateral (B)
radiographs showing a large immediately subarticular osteolytic lesion
with apparent trabeculation and a wide zone of transition proximally. A
localised area of cortical expansion is demonstrated posteriorly with a thin
overlying shell of bone.

15. • Fig. 40.12 Giant cell tumour of the distal femur. (C, D) CT sections
through the lesion demonstrating the localised dorsal expansion
and intact overlying cortex. The apparent trabeculation
demonstrated on the conventional radiographs is shown to be due
to unresorbed ridges of cortical or trabecular bone at the margins
of the lesion.

16. • Fig. 40.13 A giant cell tumour of humerus. Coronal T 1 -weighted
(A) and axial STIR (B) sequences demonstrate a large lobulated
mass in the humeral head and neck replacing all normal bone
structures. Note the close approximation to the articular surface
and the displaced axillary vessels.

17. • Fig. 40.14 Giant cell-rich osteosarcoma. (A) A radiograph of this boy at
presentation demonstrates an eccentric, purely osteolytic lesion in the upper
tibial metaphysis. The cortex has been breached but there is no periosteal new
bone and only very faint surrounding sclerosis. (B) Six months later, following
curettage and packing with bone chips, the flagrantly aggressive nature of this
tumour is obvious. Note now the Codman's triangle on the lateral aspect of the
tibial shaft and a substantial soft-tissue mass that contains ossification.

18. • Fig. 40.15 Brown tumour of hyperparathyroidism
simulating the appearance of a giant cell tumour. An
osteolytic lesion in the proximal ulna is shown extending to
the immediate subarticular region. The margins are poorly
defined and there is marked thinning and expansion of the
dorsal cortex (arrowheads). A clue to the correct diagnosis,
however, is provided by the subtle chondrocalcinosis of the
articular surface radial head (curved arrow).

19. • Fig. 40.16 Large subarticular geode mimicking a giant cell tumour. (A)
Conventional AP radiograph showing a large subarticular osteolucency
with well defined distal margins in the proximal tibia. Prominent medial
compartment osteoarthritis is shown. Sagittal T1 -weighted (B) and
coronal STIR (C) MR images showing the multiloculated cystic nature of
the tibial geode and the well-marked knee joint osteoarthritis.

20. • Fig. 40.17 Aneurysmal bone cyst arising from lamina
and internal mass of C6 resulting in a unilateral
dislocation of the facet joints in a 10 year old girl. Some
extension into the adjacent vertebra of C7 is evident.

21. • Fig. 40.18 Aneurysmal
bone cyst (boy aged
two). This film was
taken because of an
asymptomatic swelling
and shows the
characteristic features
of metaphyseal
involvement, cortical
expansion and
thinning, with a
relatively well defined
endosteal margin.

22. • Fig. 40.19 Aneurysmal
bone cyst of the
proximal fibula.
Considerably greater
expansion has occurred
in this example. The
cortex is now very thin
though apparently
intact. The zone of
transition between the
lesion and adjacent
bone is narrow but ill
defined. Note apparent
multiple septa within
the lesion.

23. Fig 40.20 Aneurysmal bone cyst of the distal tibia. (A) Coronal T 1 -
weighted image showing an expansile lesion of the distal
metaphysis containing heterogeneous areas of low signal intensity.
(B) Coronal T2 -weighted image. Apparently multiloculated high-
signal intensity expansile lesion of the metaphysis. (C) Axial T2 -
weighted image. Multiple fluid levels are demonstrated in the
vascular spaces.

24. • Fig 40.21 Vertebral haemangiomas showing
characteristic high signal intensity due to the
associated fatty matrix on both the T1 - weighted (A)
and T2 -weighted (B) images of the upper lumbar
spine. The circular nature and speckled low-signal
areas within the lesion are typical features.

25. • Fig. 40.22
Haemangioma of the
vertebral body of L3.
The whole body is
marked by the
characteristic vertical
striation, which in this
example does not
extend into the pedicles.

26. • Fig. 40.24 Haemangioma of the middle finger middle phalanx with
associated prominent soft-tissue component. (A) Conventional
radiograph showing sclerotic striated phalanx of the middle finger and
soft-tissue swelling. Coronal T 1 -weighted (B) and gradient-echo (C) MR
images showing the extensive soft-tissue component of the cavernous
haemangioma. The dilated abnormal vessels and vascular spaces
appear as characteristic low-signal serpiginous channels on the T,-
weighted sequence but have a high signal intensity on the gradient-
echo image.

27. • Fig 40.23 Axial T2 -
weighted image through
the lumbar spine showing
a vertebral haemangioma
with a substantial
extraosseous component.
This results in considerable
compromise to the thecal
sac and widening of the
right neural foramen.

28. • Fig. 40.25 Haemangioma of the inferior pubic ramus in a young woman.
(A) Conventional radiograph showing an expansile osteolytic lesion
within the inferior pubic ramus with cortical thinning and fine
trabeculation extending into the posterior column of the acetabulum. An
aneurysmal bone cyst, giant cell tumour or metastasis from a thyroid
carcinoma or renal cell tumour should be considered in the differential
diagnosis. Coronal T i -weighted (B), STIR (C) and axial T2 - weighted (D)
MR images of the pelvis show the extent of the expansile lesion within
the inferior pubic ramus and posterior acetabulum. Marked bony
expansion is evident but there is no soft-tissue component to the tumor.

29. • Fig. 40.25 Haemangioma of the inferior pubic ramus in a young woman. (A)
Conventional radiograph showing an expansile osteolytic lesion within the inferior
pubic ramus with cortical thinning and fine trabeculation extending into the posterior
column of the acetabulum. An aneurysmal bone cyst, giant cell tumour or metastasis
from a thyroid carcinoma or renal cell tumour should be considered in the differential
diagnosis. Coronal T i -weighted (B), STIR (C) and axial T2 - weighted (D) MR images of
the pelvis show the extent of the expansile lesion within the inferior pubic ramus and
posterior acetabulum. Marked bony expansion is evident but there is no soft-tissue
component to the tumor.

30. • Fig. 40.26 Haemangioma of the skull is shown
on a localised view of the temporal fossa.
Note the purely osteolytic lesion with stippled
radio densities.

31. • Fig. 40.27 Cavernous
haemangioma of the soft
tissues of the forearm is
diagnosed by the presence
of soft-tissue swelling
within which there are
phleboliths. The presence
of extensive consolidated
periosteal new bone and
bowing of the ulna suggest
an intimate relationship
with the periosteum.

32. Fig. 40.28 Vertebral haemangioma was detected initially (A) on a whole body radionuclide bone scan
in this middle-aged woman with carcinoma of the breast. A marked increase in activity is present
throughout the whole of L3. (B) A radiograph demonstrates fine striation within an enlarged
vertebral body. The pedicles, particularly that on the right, are enlarged. (C) CT confirms multiple
radiolucencies throughout the vertebral body. This patient remained free of metastasis on annual
follow-up for 5 years.

33. • Fig. 40.28 Vertebral haemangioma was detected initially (A) on a whole
body radionuclide bone scan in this middle-aged woman with carcinoma
of the breast. A marked increase in activity is present throughout the
whole of L3. (B) A radiograph demonstrates fine striation within an
enlarged vertebral body. The pedicles, particularly that on the right, are
enlarged. (C) CT confirms multiple radiolucencies throughout the vertebral
body. This patient remained free of metastasis on annual follow-up for 5
years.

34. • Fig. 40.29 Soft-tissue haemangioma of the great toe. This patient
complained of a swollen great toe with a purple area of
discoloration. (A) A plain film reveals soft-tissue swelling and
pressure erosion of the plantar aspect of the distal phalanx. (B) A
blood-pool scan confirms an intense focus of activity (arrow)
corresponding to the cavernous haemangioma.

35. • Fig. 40.30 Vanishing bone disease. A 70-yearold woman presented with poorly
localised pain in her right hip. (A) A radiograph at presentation reveals ill defined
destruction at the anterior inferior iliac spine. (B) Nine months later there is total
destruction of the whole of the hemipelvis and hip joint. Note the faint outline of
the residual femoral head (curved arrow), pathological fracture of the femoral
neck and the articular surfaces of the sacrum and symphysis pubis which no longer
articulate with bone (open arrows

36. • Fig. 40.31 Cystic
angiomatosis of bone.
Shortly before taking his
university entrance
examination this young man
complained of a vague
discomfort in his right
shoulder. Note multiple well-
defined radiolucencies
involving the acromion,
coracoid, glenoid and upper
humeral shaft. The latter has
a rather 'woodworm'-like
appearance. Lesions were
present elsewhere in the
skeleton but he had no soft
tissue abnormality.

37. • Fig. 40.32 Glomus
tumour. Intermittent
swelling of the index
finger had been present
for many years and had,
intermittently, been
exquisitely painful. A
discrete soft-tissue
mass caused pressure
erosion on the radial
side of the terminal
phalanx.

38. • Fig. 40.33 Neurofibroma arising in the exit foramen of the
first sacral segment. The patient presented with sciatic pain
and two views (A) from a water-soluble radiculogram reveal
amputation of the S1 nerve root sheath, displacement of
the S1 and S2 roots and a large well-defined rounded
radiolucency with sclerotic margins in the exit foramen. (B)
Frontal tomograms confirm a large bony defect (arrow),
compared with the normal right foramen.

39. • Fig. 40.33 Neurofibroma arising in the exit foramen of the
first sacral segment. The patient presented with sciatic pain
and two views (A) from a water-soluble radiculogram reveal
amputation of the S1 nerve root sheath, displacement of
the S1 and S2 roots and a large well-defined rounded
radiolucency with sclerotic margins in the exit foramen. (B)
Frontal tomograms confirm a large bony defect (arrow),
compared with the normal right foramen.

40. • Fig. 40.34 Neurofibroma
demonstrated by coronal T 1 -
weighted (A) and axial (B) MR
images. A typical dumb-bell
tumour is shown with large
extraneural component. Note,
however, there is extension into
the exit foramen and other
intrathecal abnormalities.

41. • Fig. 40.35 Neurofibroma arising in the
obturator ring has caused considerable
pressure erosion of both right pubic rami,
particularly the superior one. The margins of
the pressure defect are sharply defined.

42. • Fig. 40.36 Multiple
neurofibromas in the
cauda equina. This
middle aged patient was
investigated for low back
pain by radiculography.
Two large ovoid
neurofibromas (arrows)
are shown as filling
defects within the thecal
sac at the L4/5 level.

43. • Fig. 40.37
Neurofibromatosis.
Pseudarthroses of the tibia
and fibula shown in an
infant. Bowing of bone and
absence of any evidence of
bone repair are typical.

44. • Fig. 40.38
Neurofibromatosis. ,4
lateral tomogram of
the lumbar spine
demonstrates typical
posterior scalloping,
part of the general
dysplasia of the neural
canal and its contents
found in this condition.

45. • Fig. 40.39
Neurofibromatosis. A
coronal T,-weighted
sequence of the thighs
demonstrates an obvious
abnormality on the right.
In addition to a solitary
neurofibroma displacing
the femoral vessels
(shown by a signal void),
there is clear
mesenchymal dysplasia,
with extensive
abnormalities of
subcutaneous tissue and
hemihypertrophy.

46. • Fig. 40.40 Intraosseous lipoma within the calcaneum. Lateral (A)
and axial (B) conventional radiograph showing an osteolytic lesion
characteristically located between the major trabecular groups of
the bone. A thin sclerotic margin surrounds the lesion that contains
an eccentric stellate calcified focus. (C) Coronal CT of the hindfoot
establishing the fat content of the lesion.

47. • Fig. 40.40 Intraosseous lipoma within the calcaneum. Lateral (A)
and axial (B) conventional radiograph showing an osteolytic lesion
characteristically located between the major trabecular groups of
the bone. A thin sclerotic margin surrounds the lesion that contains
an eccentric stellate calcified focus. (C) Coronal CT of the hindfoot
establishing the fat content of the lesion.

48. • Fig. 40.41 Parosteal lipoma.
Two examples are shown of
parosteal lipomas arising in
middle-aged patients. Both
presented with a painless,
rather firm mass, apparently
attached to bone. (A) A large
lesion arising on the lateral
aspect of the femur. Note the
strands of ossification
surrounding the radiolucent
areas of fat. (B, C) A more
discrete tumour arises from
the interosseous membrane of
the forearm. A fatty
radiolucency is present,
together with ossification in
the soft tissues and some
periosteal bone formation.

49. • Fig. 40.41 Parosteal lipoma.
Two examples are shown of
parosteal lipomas arising in
middle-aged patients. Both
presented with a painless,
rather firm mass, apparently
attached to bone. (A) A large
lesion arising on the lateral
aspect of the femur. Note the
strands of ossification
surrounding the radiolucent
areas of fat. (B, C) A more
discrete tumour arises from
the interosseous membrane
of the forearm. A fatty
radiolucency is present,
together with ossification in
the soft tissues and some
periosteal bone formation.

50. • Fig. 40.42 Chordoma of the distal sacrum. (A) A lateral film demonstrates
a large soft-tissue mass displacing bowel anteriorly. The anterior cortex of
the distal sacral vertebrae is ill defined and the coccyx is not seen. (B) CT
demonstrates the typical well-defined soft tissue mass extending
anteriorly from the sacrum. The anterior cortex of the sacrum has been
destroyed. Chordomas usually exhibit an apparent disproportion between
the size of the soft-tissue mass and the extent of the bony involvement.

51. • Fig. 40.43 Implantation dermoid cyst. A cystic lesion
in the terminal phalanx of the thumb was found in an
elderly woman many years after a penetrating injury.
The sharp definition of its margins and the location of
the lesion are characteristic.

52. • Fig. 40.44 Synovial
chondromatosis.
Hundreds of calcified
lesions are shown in
relation to the
synovium, all of them
approximately the
same size. Nearly all
were loose bodies at
arthroscopy.

53. • Fig. 40.45 Synovial chondromatosis of the knee. (A) Axial
T2 - weighted fat-suppressed image showing numerous low-
signal-intensity filling defects within the joint and thickened
nodular synovium due to intrasynovial calcification. (B) In
another patient a number of ossified masses of uniform size
are present in a popliteal cyst. Medial compartment
osteoarthritis is evident.

54. Fig. 40.46 Pigmented villonodular synovitis of the hip. (A) The conventional
radiograph illustrates sharply defined radiolucent defects involving the acetabulum
and the femoral head and neck. (B) The sharply defined nature of the lesions
confirmed on tomography. Note the sclerotic. This patient has relatively advanced
disease and joint space narrowing is present. (C) In another patient the well-
defined radiolucencies are confined to the acetabular side of the joint and the
joint space is preservedor widened.

55. Fig. 40.46 Pigmented villonodular synovitis of the hip. (A) The conventional
radiograph illustrates sharply defined radiolucent defects involving the
acetabulum and the femoral head and neck. (B) The sharply defined
nature of the lesions confirmed on tomography. Note the sclerotic
margins. This patient has relatively advanced disease and joint space
narrowing is present. (C) In another patient the well-defined
radiolucencies are confined to the acetabular side of the joint and the
joint space is preserved or widened.

56. • Fig. 40.47 Pigmented villonodular synovitis of the hip.
Coronal T1 -weighted (A) and STIR (B) sequences
demonstrate a lobulated synovial mass on the right
with modestly high signal on the STIR sequence,
though less so than the joint effusion associated with
it. Note the replacement of the pulvina on the T i -
weighted sequence by tumour.

57. • Fig. 40.48 Pigmented villonodular
synovitis of the index finger
metacarpophalangeal joint. (A) An
arthrogram confirms an enlarged joint
space and thickened nodular synovium.
In another patient the corresponding MR
features are shown on coronal T 1 -
weighted contrast-enchanted (B) and T2
-weighted fat-suppressed (C) images.

58. • Fig. 40.49 Pigmented villonodular synovitis of the knee
joint. Axial T,-weighted (A) and T2 -weighted fat-
suppressed (B) MR images through the patella and
suprapatellar recess showing a heterogeneous mass within
the joint made up of fat, haemosiderin, fibrous tissue and
cellular elements.

59. • Fig. 40.50 (A,B) Pigmented villonodular synovitis of
the flexor tendon sheath of the middle finger. A
sharply circumscribed soft-tissue mass has caused
slight pressure erosion of the middle phalanx.

60. • Fig. 40.51 Lipoma arborescens of the knee joint. Axial T1 -weighted
(A) and T2 -weighted (B) fat-suppressed MR images through the
suprapatellar recess showing numerous fatty fronds of synovium and
a large joint effusion. Note how the high signal intensity villous
projections on the T,-weighted image are suppressed on the T2 -
weighted fat-suppressed sequence.

61. • Fig. 40.52 Dialysis-related amyloidosis of the hip
resulting in pressure like erosions of the femoral neck.
Note the coarsened quality of the trabecular bone due
to secondary hyperparathyroidism.

62. • Fig. 40.53 Dialysis-related amyloidosis of the knee.
Axial T1 -weighted (A), sagittal proton density (B) and
T 2 -weighted (C) MR images showing numerous
erosions of the margin of the tibia and characteristic
low-signal-intensity masses within the synovium, most
evident posteriorly within the popliteal cyst. A large
joint effusion is also present.

63. • Fig. 40.54 Synovioma.
A large soft-tissue
mass is present
posterior to the distal
femur within which
there is some
amorphous
eccentrically located
calcification.

65. • Fig. 40.56 Intraosseous ganglion of the
proximal fibula shown at a typical location. A
slightly expansile lytic lesion is evident with
endosteal thinning of the cortex and a well-
defined margin.

66. • Fig. 40.57
Intraosseous
ganglion. An oval,
eccentric,
osteolytic lesion
arises from the
medial malleolus
with a thin
sclerotic margin.

67. • Fig. 40.58 Subarticular geodes. (A) An elderly female with
rheumatoid arthritis and secondary degenerative arthritis has a
typical, large geode immediately beneath the articular surface of the
tibia. (B) A younger male with rheumatoid disease has an oval, well-
defined defect in the upper femoral neck. This too has a sclerotic
margin. (C) Aspiration of the defect yielded synovial fluid and
injection of contrast medium confirmed communication between the
subarticular geode and the joint cavity.

68. • Fig. 40.59 Solitary bone
cyst of the proximal femur
showing expansion and
thinning of the cortex,
clearly defined endosteal
margins but no
calcification or periosteal
new bone formation.

69. • Fig. 40.60 Solitary bone of the cyst proximal humerus. (A) This child presented with
a pathological fracture through this long centrally located lytic lesion. Endosteal
thinning and slight expansion is evident. There is no periosteal reaction and the distal
extent of the lesion is well defined. Some 'fallen fragments' are present near to the
fracture site. Coronal T1 -weighted (B), T2-weighted (C) and T 1 -weighted (D)
contrast-enhanced fat-suppressed images. The extent of the lesion is well shown and
is confined to the medullary canal of the humerus. Only the margins enhance
consistent with a fluid-containing lesion. Some adjacent soft-tissueenhancement
results from the fracture.

70. • Fig. 40.60 Solitary bone of the cyst proximal humerus. (A) This child presented
with a pathological fracture through this long centrally located lytic lesion.
Endosteal thinning and slight expansion is evident. There is no periosteal reaction
and the distal extent of the lesion is well defined. Some 'fallen fragments' are
present near to the fracture site. Coronal T1 -weighted (B), T2-weighted (C) and T 1
-weighted (D) contrast-enhanced fat-suppressed images. The extent of the lesion is
well shown and is confined to the medullary canal of the humerus. Only the
margins enhance consistent with a fluid-containing lesion. Some adjacent soft-
tissue enhancement results from the fracture.

71. • Fig. 40.61 Solitary bone cyst arising in a
typical site in the os calcis. The margins in this
bone tend to be less well defined.

72. • Fig. 40.62 Solitary bone cyst of the distal femur. The lesion is rather atypical (A), and plain film
diagnosis is not easy. However, it illustrates how further investigations can help in differential
diagnosis. A bone scan in the blood pool phase (B) and in the delayed phase (C) shows increased
activity around the margin of the lesion corresponding to sclerosis on plain film. (D) A CT scan
demonstrates a soft-tissue density expansile lesion with no calcification. The differential diagnosis
includes aneurysmal bone cyst, fibrous dysplasia ( monostotic) and a chondroma. Aneurysmal bone
cyst is vascular in the blood-pool phase of a bone scan, fibrous dysplasia markedly so on the
delayed scan. Calcification may be expected on CT in a chondroma.

73. • Fig. 40.62 Solitary bone cyst of the distal femur. The lesion is rather atypical (A),
and plain film diagnosis is not easy. However, it illustrates how further
investigations can help in differential diagnosis. A bone scan in the blood pool
phase (B) and in the delayed phase (C) shows increased activity around the margin
of the lesion corresponding to sclerosis on plain film. (D) A CT scan demonstrates a
soft-tissue density expansile lesion with no calcification. The differential diagnosis
includes aneurysmal bone cyst, fibrous dysplasia ( monostotic) and a chondroma.
Aneurysmal bone cyst is vascular in the blood-pool phase of a bone scan, fibrous
dysplasia markedly so on the delayed scan. Calcification may be expected on CT in
a chondroma.

74. • Fig. 40.63 Ewing's sarcoma. The only
abnormal sign here is of lamellar periosteal
new bone arising from the superior pubic
ramus on the right.

75. • Fig. 40.64 Ewing's
sarcoma. This tumour
is much more
advanced, with a well-
defined soft-tissue
mass, Codman's
triangles, ossification
and calcification in the
soft tissues and ill-
defined bony
destruction. The
radiological distinction
from osteosarcoma is
difficult.

76. Fig. 40.65 Ewing's
sarcoma arising
primarily in the soft
tissues of the thigh. A
well-marked erosion
('saucerisation') defect
has been caused with
periosteal new bone
formation. type of
periosteal reaction is
classically

77. • Fig. 40.66 Ewing's sarcoma of bone arising in the proximal fibula of an 8 year old. (A) An advanced
tumour is shown on plain films, with Codman's triangles, a soft-tissue mass and ill-defined bone
destruction. (B) The subtraction print of a femoral arteriogram demonstrates a very abnormal
circulation with a large soft-tissue mass. (C) A bone scan, in the delayed phase, demonstrates
increased activity where new bone formation is present on plain films. The lesion itself is photon
deficient. Osteosarcoma may presentsi milar appearances.

78. • Fig. 40.66 Ewing's sarcoma of
bone arising in the proximal
fibula of an 8 year old. (A) An
advanced tumour is shown on
plain films, with Codman's
triangles, a soft-tissue mass and
ill-defined bone destruction. (B)
The subtraction print of a femoral
arteriogram demonstrates a very
abnormal circulation with a large
soft-tissue mass. (C) A bone scan,
in the delayed phase,
demonstrates increased activity
where new bone formation is
present on plain films. The lesion
itself is photon deficient.
Osteosarcoma may presentsi
milar appearances.

79. • Fig. 40.67 Ewing's sarcoma of a lower rib.
The conventional radiograph (A) shows a
long moth-eaten lesion of the eleventh
right rib which demonstrates prominent
increased scintigraphic activity on the
posterior bone scan (B). The extent of the
associated soft-tissue mass, however, is
best demonstrated on the CT (C) of the
upper abdomen (dynamic enhanced scan).

80. • Fig. 40.68 Ewing's sarcoma
of the anterior aspect of the
right second rib. (A) On the
conventional radiograph the
appearances simulate an
intrapulmonary lesion. (B) CT
section showing destruction
of the second rib and
associated soft-tissue mass.
(C) On the axial T 1 -
weighted image the soft
tissue component of the
lesion has an intermediate
signal intensity, and with the
STIR sequence (D) an
extremely high signal
intensity.

81. • Fig. 40.68 Ewing's sarcoma
of the anterior aspect of
the right second rib. (A) On
the conventional radiograph
the appearances simulate
an intrapulmonary lesion.
(B) CT section showing
destruction of the second
rib and associated soft-
tissue mass. (C) On the axial
T 1 - weighted image the
soft tissue component of
the lesion has an
intermediate signal
intensity, and with the STIR
sequence (D) an extremely
high signal intensity.

82. THANX YOU